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.

Support your local general practitioner

As we continue to discuss cost-effective medicine, the need for health insurance reform and other topics du jour, I'd like to take a moment to focus on a rather relevant aspect of health policy. This is a topic that everyone probably has heard about, but one that no one is quite sure how to address. Current evidence suggests health systems focusing on primary care provide greater access to higher quality care and at lower costs. As current health reform continues to be debated, this issue becomes particularly important for primary care physicians seeing the effects of the current system every day. It is one thing to discuss support of health for every American, it is quite another to actually do it - and I'm not talking just about insurance. We need support for physicians who are going to go into general practice - either general internal medicine, general pediatrics, or family medicine. It isn't realistic to expect highly trained specialists to manage multiple social issues and address the complex nature of multiple chronic medical problems for all their patients, but as the majority of medical graduates go onto practice in specialties like cardiology, orthopedics, radiology and anesthesia, there are fewer generalists to go around.

I'd like to make the case that generalists - be they internal medicine docs who see adults, pediatricians who see kids, or family physicians who do both, are best suited to address the health care needs of the majority of patients of all ages and in all geographic areas throughout the United States. In fact, we already know that health systems which emphasize generalist ("primary") care provide higher quality care at lower cost (1, 2). Other studies are finding evidence that obesity and related medical conditions decrease when there are enough generalists practicing in a community (3). Communities in which there is a higher proportion of generalists also benefit from:

• reduced all-cause mortality
• decreased emergency room and hospital utilization rates
• reduced medical waste from unnecessary testing and procedures
  

What is interesting to know is that not all generalists are trained in the same way, and so the number of practicing generalists tends to vary by type of training program. For example, statistics about graduating and practicing physicians demonstrate that the doctors most likely to practice general ("primary care") medicine throughout their careers are family physicians. Approximately 90% of family medicine physicians-in-training ("residents") go on to practice general primary care medicine for their entire careers. For pediatricians, only 75% of pediatrics residents continue to practice primary care, and only 19% of internal medicine doctors continue to practice general medicine while the remaining group of trainees go on to specialties or sub-specialties in particular areas of care like cardiology, nephrology, sports medicine and the like (4). Family medicine is the only discipline where training is exclusively dedicated to primary care. Family physicians receive training in six major clinical areas: pediatrics, internal medicine, obstetrics/gynecology, psychiatry/neurology, surgery and community medicine. They also receive instruction in geriatrics, emergency medicine, ophthalmology, radiology, orthopedics, otolaryngology and urology. As a result, family physicians are capable of providing a majority of health care that people need on an ongoing basis. These types of physicians are also more likely to practice in underserved areas, like rural areas or inner-city community clinics, where the need is greatest. Our society needs general practitioners. We are not made up of organs only, we are human. We need someone to be looking at the whole picture, someone to help us discuss end-of-life care issues with our families and elderly parents. Someone who can explain why it is important for a family member to see three different doctors to control her diabetes and heart failure. The system is too complex to assume patients can navigate the waters on their own...which may be why patients with chronic conditions often see the progression of their disease as something beyond their own control.

I believe that until we truly support incentives to increase the number of general practitioners, the health needs of our country will continue to go unmet - whether health insurance reform passes or not. I am not suggesting that we choose which areas of medicine students select as their specialty, or even that we require service in primary care of every trainee. What I am suggesting is that we need to recognize that the results of health care personnel shortages, increased need for doctors that practice in rural areas, and increased need for doctors who can care for the elderly and geriatric population, will place a heavy burden on our already crippled health system. We must decide how to address the issue creatively, so that we have an adequate supply of generalists who can treat chronic disease and work with their patients to prevent complications of those diseases. These are not conditions that can be easily fixed by a surgeon or a heart doctor working in a specialty group. We need generalists who can coordinate care for the elderly, who can work directly with social services and other members of the health care team, and who can devote a 15 minute visit to a discussion about quitting smoking or lifestyle changes to increase a persons level of activity. Otherwise, we risk becoming a population of overweight amputees on dialysis as a result of "poorly controlled" chronic disease.

(1) Macinko, J, et al. The Contribution of Primary Care Systems to Health Outcomes Within OECD Countries, 1970-1998. Health Serv Res 2003 June; (3):831-65.
(2) Starfield B, et al. Contributions of Primary Care to Health Systems and Health. The Millbank Quarterly, Vol 83 (3) 2005, 457-502.
(3)Gaglioti A, et al. Primary care's ecologic impact on obesity. Am Fam Physician. 79(6):446.
(4) Althouse, L and Stockman J. Pediatric workforse: a look at general pediatrics data from the American Board of Pediatrics. Journal of Pediatrics 2006, 148(2): 166-9.

Designing our Health

As our Congressional representatives and Senators continue to negotiate and compromise in order to draft a universal piece of health reform legislation, I am reminded of a statement paraphrasing Virchow:

"Medicine, if it is to improve the health of the public, must attend at one and the same time to its biologic and its social underpinnings. It is paradoxic that at the very moment when the scientific progress of medicine has reached unprecedented heights, our neglect of the social roots cripples our effectiveness." (Eisenberg 1984)

These words could not have rung more true than in a recent visit with one of my new patients. For purposes of the example, let us call him Mr. Smith. He is a 40-something gentleman, a 2 pack-a-day smoker, who has never needed to visit a doctor in his adult life until two weeks ago when he could not catch his breath and was running a high fever. Mr. Smith was seen in the emergency room, treated, and told to "follow up with his regular doctor" for further management of his severe obstructive lung disease - likely a consequence of his 30 year smoking history. Fortunately, he had health insurance and the fact that he didn't have a regular doctor was not lost on him.

So he ambled into my office for the first time last week for a check-up. At first glance Mr. Smith was slightly out of breath but an otherwise healthy-looking gentleman, with an athletic physique. As I talked with him, it became clear that he was struggling at his construction job primarily because he could not catch his breath; and his single inhaler was not relieving his symptoms. He told me that he didn't want to quit his job because he would lose his health insurance, but that he was worried that he would get fired if he could not do his duties as a result of his current state of health. He also informed me that he was running out of his medication, but could not afford the $30 co-pay at the pharmacy to pick up his remaining refill. "Doc," he said, "I have to put food on the table and pay the rent, you know."

This is a situation many of us have heard before - either spoken by a politician stumping for votes, or by community members advocating for a better system of care. It is a different feeling entirely when you in a position having a direct effect on another person's health. As I talked with Mr. Smith, I felt that he had two outcomes that I could predict with cold certainty: (1) that he begin to use a (cheap, generic, available) medication which I wanted to prescribe that day, even if that meant sacrificing some other purchase this month, and would therefore receive the treatment he needed; or (2) that he not obtain his medications which would undoubtedly result in another expensive trip to the emergency room. Some of you may be thinking "I bet those cigarettes cost money - couldn't he choose between medicine and cigarettes instead?" The answer, of course, is yes. But does the visit end there? Could I say that to this patient and believe - really believe - that would be enough? That I would have done everything I could for my patient? Yes, it is true that his lung condition is likely due to cigarettes. Yes, he probably could afford the medication if he quit smoking. And yes, I do believe that my patient has a responsibility to himself to make that decision to quit...and I want to help him quit as part of his overall health care plan. But quitting smoking takes time, discipline and - let's face it - hard work. So what to do in the meantime while he works on quitting completely?

The above example is just one of many stories health professionals collect on a daily basis - and it demonstrates just how interconnected our well-being is to all aspects of our society including the health system. In reviewing the national health reform bills with the above story in mind, it occurred to me that our current health system is perfectly designed - to result in the current health outcomes that we see every day:
(1) most health insurance is linked to employee status; so if one gets sick or loses a job, it becomes very difficult and expensive get care, see a regular doctor, or obtain basic health services
(2) as a society we value advances in medical technology that provide quick relief or immediate treatment, so our care is often expensive and less sustainable than cheaper, long-term alternatives
(3) our environment and lifestyles often do not promote our making healthy choices

So, what do we do about it? Do we lose hope in the current process? Do we shrug and say "well, health reform would have been nice, but you can't win 'em all"? The reality is that we must make difficult decisions about how we will use available resources to improve our health. This is the very essence of why national health reform is so important and essential to our welfare. Is it really the best use of our time, energy and money if some of us can afford all kinds of extra health care, and others of us must choose between an office visit with a $40 co-pay and dinner? The fact is that despite what special interests in Washington DC will tell you, most people in our country support health reform once they are made aware of the specifics contained in the legislation (Kaiser Family Foundation 2010). For those of us who have been in a room with someone like Mr. Smith, that fact alone makes all the difference in our hope for a system designed to improve our health.

Place-based policy

I recently had the privilege to attend the semi-annual CCLHO (California Conference of Local Health Officers) meeting in Oakland, California. This meeting represents an opportunity for county public health officers (often physicians) to collaborate with each other face-to-face. It is a time for those involved in the day-to-day work of public health to connect withpeers, discuss county-wide approaches to current public health issues (like H1N1 flu), and to attend educational sessions about new or alternative approaches to improving the health of Californians. An incredible amount of thought, hard work, and creativity filled our three-day conference, and there was no shortage of discussions about H1N1 preparedness, vaccine distribution and disaster planning. However, one portion of the conference focused our energies toward a more fundamental topic: that of health inequities in California.

Health inequities are probably best defined as “differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random differences or differences caused by those who become ill” (1). The implication is that there are structural or system effects in our society which are borne out by how we each live our daily lives. If you think about it, "health" is a result of not only what we choose to do on a daily basis (eat healthy food, exercise, connect with our family and friends), but what we are able to do based on our surroundings. For example, can everyone readily obtain daily servings of fruits and vegetables? Do we have time to sit down and enjoy our lunch with co-workers? Are we able to go jogging every other day? Can we take our kids out to the park on the weekends for some fresh air?

These questions bring us to the idea of place. What role do our physical surroundings play in our health decisions and our health status? If you consider that for some of us it is easier to obtain locally grown fresh fruits, and that for some of us going jogging in the evening is considered extremely unsafe, then place has a lot to do with our daily health choices, and with our overall health status both as individuals and as members of a larger community. This is not a new idea, but it is becoming continually important as local health departments and public health officials seek to reduce rates of chronic disease and mortality in their own communities. It might not be “health policy” as we usually think of it (changing how we deliver care in community clinics or reducing health insurance premiums), but it turns out that small changes in certain place-based policies can have a profound effect on health status. The 2008 report Health Inequities in the Bay Area, produced by a collaboration of public health departments, elegantly demonstrates that our collective health status and life expectancy is directly tied to where we live, our levels of income and wealth, our ethnicity, immigration status, educational attainment and the degree of inequality in our surrounding communities (2). Other data suggest that only approximately ten percent of our health can be directly attributed to improvements in health delivery; in one study reviewing data from the years 1991 - 2000, an estimated 177,000 deaths in the U.S. were averted because of advances in medical technology. However, that same study estimated that if we were to eliminate the disparity between African Americans and Whites, we would have avoided over 886,000 deaths (3).

Many people have written on this topic and it is a well-known concept in many public health departments in California, but the applicability of the ideas are only slowly being realized in state legislation or county regulations. Not that any of this is easy; it takes true collaboration and coalition building to make our communities into healthy places for all. The essential point that I want to reiterate with this blog post is that we can’t necessarily get better health outcomes if we focus solely on changing health care delivery, health care institutional policy, or health insurance policy. We need to think about health in broader terms, because health policy is education policy as well as insurance policy; it is social policy as well as health care delivery. It is how we live our lives, and how we are able to live our lives that determines the degree to which we use and need the current health care system. If we consider the current national health reform process in the context of place-based policy, it is clear that health insurance is only one of the determinants that affect our overall health.

(1) Whitehead, Margaret M. 1992. The Concepts and Principles of Equity and Health. International Journal of Health Services 22(3):429.
(2) Health Inequities in the Bay Area. BARHII 2008. Available at: http://www.barhii.org/press/download/barhii_report08.pdf. Accessed 11/3/09.
(3) Wilkinson R., Marmot M. (eds). Social Determinants of Health: The Solid Facts. 2nd Edition, Copenhagen: World Health Organization, 2003.

Health insurance reform and the importance of the medical loss ratio

Last weekend, I eagerly went to a town hall hosted by Congresswoman Doris Matsui. The topic was the current health reform process, and I was interested to hear the discussion and possibly have a chance to participate in the forum. (For additional news coverage of the town hall, see the article in the Sacramento Bee). No one threw a chair or defaced public property, but it was clear that health reform was a hot topic and there was a great deal of shouting, clapping, booing and placard waving. Constituents voiced their frustrations, and perspectives about health insurance reform in many ways and from many different perspectives. A common theme, however, was heard as one participant after another voiced frustration with high health insurance premiums, limitations of care, and escalating personal costs of care. I didn't have an opportunity to ask a question of Representative Matsui, but I think it was particularly revealing that so many people asked her to comment on how the reform process would address insurance company practices.

In reality, the current health reform is health insurance reform, rather than full system reform. Health insurance is one, and only one, part of the larger system of health care in this country. I think many people would agree that aspects of care delivery, patient safety, pharmaceutical sales policies and other elements of the health care system are in need of reform. Nevertheless, health insurance companies are a major driver of cost of care in the US health care system, and the town hall discussion was so focused on health insurance policies and company profits that the term medical loss ratio was actually mentioned several times. Though not a concept well known outside the circle of health economists, it is one that serves to illustrate the importance of the current reform efforts.

The medical loss ratio is a term which describes the ratio between what a health insurance company pays out in claims for actual health care services, and what the company spends on sales, marketing, administration, and profit. If a relatively healthy person is insured at company A, and paying a premium of approximately $2500 per year (1) but does not visit the doctor regularly or uses minimal health services, the health insurance company can devote most or all of that premium towards non-health related expenses (advertising, shareholder dividends, etc). In this case, their medical loss ratio is relatively small. Compare that to a person with multiple medical conditions who sees a physician multiple times a year, and you can imagine that the insurance company is paying more per month towards health services for that person and less money towards non-health expenses. Right now, there are no federal laws that require health insurance companies to devote any percentage of premiums towards health services. This means that if a really sick person is insured at company A, the company might require that individual to pay a certain percentage of care out-of-pocket in order to limit the companys' medical loss. Essentially, a health insurance company is likely to earn more profit if it has to pay less for health services. To "drive down medical loss," a health insurance company could choose to selectively insure relatively healthy people so that the company will be more profitable.

This is one of the main reasons we need the current reform effort to succeed; so that policies developed at the national level will limit the degree to which insurance companies can drive down their medical losses. Yes, health insurance companies are a business and therefore have a responsibility to demonstrate profit to shareholders. In most markets, the incentive to increase profits can provide a powerful stimulus to innovate, create and drive further efficiencies in an industry. However, in the health industry, this profit incentive also stimulates creative mechanisms to drive down medical loss, such as rescinding health coverage for people who are found to have pre-existing conditions, or raising premiums to unrealistically high levels in the hopes of losing some customers who cannot afford the rate increase. This results in higher costs (both monetarily and clinically) for the sickest people in our country and for all of us who pay insurance premiums.

The basic premise currently serving as a foundation for ideas and proposals within the House and Senate health reform bills is that health care is, primarily, a business. As one who believes there are serious market failures in the system (as illustrated by the medical loss ratio), I have struggled with the business premise as a place to begin forming my opinions about the current reform effort. It's not that I believe health care is not a business, but that it is much more than a market-based business. I believe health care represents a service, a public good, and a business that serves both individuals and communities nationwide. This changes the ways we could structure our economic and policy analyses of the current system and of reform. That said, I do accept that (a) reform must start somewhere and (b) the current economic climate makes a "start from scratch" approach less-than-feasible. Nevertheless, I hope the current reform effort is a starting place for further discussion about improving the overall health care of the nation, and not just a debate about how to create fair health insurance policy.

(1) Trends and Indicators in the Changing Health Marketplace. Exhibit 3.5: Average Monthly Employee Premium Contributions. http://www.kff.org/insurance/7031/ti2004-3-5.cfm
Accessed 10/15/09.