Can Medicaid solve our ills?

In Pennsylvania, only 2 out of 3 physicians are willing to take on new Medicaid patients

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In his speech to Democratic delegates last week, former President Bill Clinton's remarks eventually turned toward Medicaid and to President Barack Obama's signature domestic policy achievement, the 2010 Affordable Care Act, which seeks to expand Medicaid coverage to millions of newly eligible patients.

That's the good news, if you are poor and lack health care.

The bad news is this -- if you're a Pennsylvanian who is newly enrolled in the state's Medicaid health insurance program for the poor, only 2 out of 3 physicians in the state are willing to see you, according to new research.

Those odds are almost exactly in the middle of the pack -- a better chance than you'll find in the nation's most populous states, but far worse than the rural states in America's flyover region where almost all physicians are willing to accept new Medicaid patients.

PG graphic: Physicians accepting new Medicaid patients
(Click image for larger version)

Medicaid has low reimbursement levels compared to private insurance and compared to the federal Medicare program for seniors, meaning doctors don't get paid as much for providing services to Medicaid patients.

And that means some primary-care physicians simply won't take on new Medicaid patients or have opted out of Medicaid altogether, which is a concern for public health advocates.

Nationally, about 64.7 percent of primary-care physicians accept new patients with Medicaid coverage. That's well below the acceptance rate for new patients with private insurance, which stands at about 81 percent for all physicians, including specialists.

The percentages don't tell the full story, said Cindy Mann, deputy director with the Centers for Medicare & Medicaid Services in Washington, D.C.

"It's a broader health care delivery supply question," she said. "The ACA gives us some new tools to boost the supply of care providers," beyond the traditional primary-care physician model. Medical care homes, nurse practitioners and physician assistants will all be bigger part of the health care system -- and the Medicaid provider network -- going forward, to ensure adequate networks and access.

But opponents of "Obamacare" and its expanded Medicaid mandate say the percentages prove that paying doctors less, as Medicaid does, won't lead to improved care or wider access -- it will instead lead to a round-robin search for physicians willing to be paid about half of what they'd make for treating a patient with private insurance.

It could also lead to lesser outcomes for patients, since people on Medicaid have a tougher time finding physicians and scheduling timely appointments than people with private insurance.

In Pennsylvania, about 68 percent of doctors are taking on new Medicaid patients as of 2011, according to a study published in the journal Health Affairs, conducted by Sandra Decker, a National Center for Health Statistics economist.

Pennsylvania's "new" patient acceptance rate is better than the rate in neighboring New York (62 percent), Maryland (66 percent) and New Jersey (40 percent), but worse than Ohio (72 percent), West Virginia (81 percent) and Delaware (78 percent).

The states in which physicians are most readily accepting new Medicaid patients are Wyoming (99 percent), Minnesota (96 percent) and North Dakota (95 percent); the worst are New Jersey, California (57 percent) and Florida (59 percent).

Alan Yeasted, Mt. Lebanon-based governor of Pennsylvania's American College of Physicians chapter, said the percentages may not reflect an unwillingness on the part of primary-care physicians to take on new Medicaid patients, but rather a general crunch in the physician population, one that could be exacerbated when more people enter the ranks of Medicaid enrollees.

"There is somewhat of [a] shortage of PCPs," and a bigger one looming in the future, Dr. Yeasted said. "Everyone would agree with that ... [but] the physicians in Western Pennsylvania have been relatively good about accepting Medicaid."

Supporting Dr. Yeasted's contention that this is more a shortage issue than a Medicaid issue is recent Pennsylvania Department of Health research, which says 94 percent of "rural" doctors and 84 percent of "urban" doctors currently see Medicaid patients.

That means that nearly all doctors are willing to work within Medicaid and its low rates, but it also means that some physicians already have so many patients that they can't take on any new patients, regardless of stripe -- Medicaid, Medicare or privately insured.

In states with the lowest Medicaid reimbursement rates, though, "You will have difficulty finding a physician who will accept Medicaid in the future," Dr. Yeasted said.

He does not include Pennsylvania among those states -- here, Medicaid payment rates are about 40 percent lower than Medicare rates for the same services, but that's fairly average, since different states reimburse for Medicaid at different payment levels.

In the short term, though, the variations among states when it comes to Medicaid payments to doctors should be smoothed by a separate provision of the Affordable Care Act. That provision equalizes Medicaid and Medicare reimbursement rates in 2013 and 2014 for primary-care physicians -- those in family medicine, internal medicine and pediatric care -- so long as their home state agrees to participate in the expanded Medicaid program, which not all states are keen to do.

The hope is that the "equalized" rates will not only be fairer to those doctors already seeing Medicaid patients, but will also be attractive to those physicians who had been declining to see new Medicaid patients.

The strategy will probably work, to at least some degree, according to the research published by Health Affairs. The study predicts that equalizing Medicare and Medicaid payments will, temporarily at least, increase the Medicaid acceptance rate among all doctors -- specialists included -- to 78.6 percent, which is comparable to the private insurance new-patient acceptance rate of 81.7 percent.

But in states that are declining to participate in the Medicaid expansion, the status quo will reign. Texas is one of those states -- Republican Gov. Rick Perry, in the aftermath of the U.S. Supreme Court decision that rendered the Medicaid expansion optional, is already on record saying his state will reject the Medicaid expansion and all the extra funding that would come with it.

The result is more than a million would-be Medicaid patients won't be eligible, said San Antonio's John Holcomb, a pulmonary specialist and chair of the Texas Medical Association's Medicaid research committee.

Texas will continue to see more and more physicians turning away Medicaid patients, he said, noting that even physicians who say they take Medicaid can be quite selective. "When you actually call the doctor's, you can't get [an appointment]," he said.

Several studies, including one conducted by the University of Pennsylvania and published in 2011, suggest that patients with public insurance -- especially Medicaid and CHIP (the Children's Health Insurance Program) -- "are less likely to receive specialty care" than patients with private insurance.

"It's common sense -- if you underpay doctors, you'll get less access to them," said Avik Roy, a health care investment analyst and a member of GOP presidential candidate Mitt Romney's health care policy advisory team. "The problem will get worse over time because Medicaid reimbursements continue to go down," except for the temporary two-year bump for primary care.

The equalized payments, he said, "will have no impact" on overall physician acceptance rates, "because if they take a Medicaid patient and the reimbursement rates revert back, they'll feel ethically obligated to continue caring for those patients at a financial loss."

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Bill Toland: or 412-263-2625. First Published September 9, 2012 4:00 AM


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